GESTATIONAL CONDITION: 1ST
TRIMESTER BLEEDING
ECTOPIC PREGNANCY
 Implantation (of blastocyst)
occurs outside the uterine cavity
either in the surface of the ovary
or the cervix
 Common in the fallopian tube
o 80% in the ampulla
o 12% in the isthmus
o 8% in interstitial/fimbria
o Fallopian tube cannot
accommodate the needs of
baby, cannot enlarge in size
 Assessment:
o Amenorrhea
o Sharp knife stabbing pain in
the lower abdominal
quadrants
 If pregnant, there is
no pain
o Scant vaginal spotting
 Increase blood loss
o Shock (rapid thready pulse,
rapid RR, decrease BP)
o Leukocytosis – elevated
WBC
o No gestational sac during
UTZ
o Rigid abdomen
o Umbilicus develop a bluish
tinge (Cullen’s sign)
 Most important sign
o Extensive or dull vaginal and
abdominal pain
o Movement of the cervix and
pelvis exam causes
excruciating pain (cervical
motion tenderness)
o Shoulder pain
 Accumulation of
blood in the
peritoneal
area/diaphragm that
irritates the phrenic
nerve
 Risk factors:
o Obstruction
 Adhesion in FT from
previous infection
 Prevents the
movement of egg cell
o Congenital malformations
 Abnormalities of FT
o Scars from tubal surgery
 Prevents the egg cell
o Uterine tumor
 Prevents the
implantation
 Tends to occupy FT
MANAGEMENT
1. Unruptured pregnancy
 FT is still intact but only the
client feels pain at LQ and
scant bleeding
 Oral administration of
methotrexate
o Has sclerotic effect
o Could easily shrink and
absorb products of
conception
 Hysterosalpingogram or UTZ
o Using dye
 o Cover or color the
uterus and FT
o If it flows smoothly,
there is no obstruction
o Some will be allergic to
the dye
o Difficulty of breathing –
side effect
o Can be done midway
before menstruation, 6-
12 days before
menstruation
 Mifepristone – abortifacient
o Destroys the products
of conception
2. Ruptured ectopic pregnancy
 Cullen’s sign, rigid abdominal
 Blood sample is drawn
immediately
o Hgb, typing, hcg level
 IVF
o Decrease blood volume
 BT
 Therapy: laparoscopy
o Remove damaged FT
 Rh (D) immune globulin
 Culdocentesis – aspirate blood
from cul-de-sac (posterior
portion of ovaries)
o Consent
o Lithotomy position
o Prepare perineum
o Speculum is introduced
o Spinal needle directed
to posterior portion of
the cervix
 Result:
o If blood is present in
the cul-de-sac –
ruptured ectopic
o If non-clotting/leaked
blood – ectopic
pregnancy)
o If blood clots – maternal
blood
 E – extrauterine pregnancy
 C – Cullen’s sign
 T – tender, rigid, abdominal
pain (LQ), amenorrhea
 O - observe for shock
 P - prepare for surgery
(laparoscopy)
 I – inject Rhogam
o To prevent Rh blood
incompatibility
 C – care for the client
ABORTION
 Medical term for any interruption
of pregnancy before a fetus is
viable
 Viable fetus – fetus of more than
20-24 weeks gestation
 Early miscarriage – occurs before
16th week (4 months)
 Late miscarriage – occurs between
16th and 24th weeks (4-6 months)
 1st 6th week – developing placenta is
tentatively attached to the
deciduas
 6-12 weeks – a moderate degree of
attachment to the myometrium
 After 12 weeks – attachment is
penetrating and deep
 o Vaginal spotting – more o Avoid strenuous activity
bleeding for 24-48 hours
 Bleeding before 6 weeks – severe o Once bleeding stops, can
o Risk of baby lost resume activity
 Bleeding after week 12 – profuse o Coitus is restricted for
 Causes: 2 weeks
o A – abnormal fetal  Could lead to
development infection
o B – bleeding due to o For dilation and
implantation abnormalities curettage
o O – ovary fails to produce  Raspa
progesterone 2. Imminent/inevitable
o R – recurrent systemic  s/s
infection o cervical dilatation and
o T – teratogenic drug uterine contraction
 Pregnant clients o moderate vaginal
should not be taking bleeding
drugs w/o o severe/painful cramping
prescription o cervix is open
 Assessment:  txt
o Vaginal spotting o ask to come to the clinic
o Lower abdominal cramps and bring tissue
o Fever and body malaise fragments to be
o Signs of infection examined
o vacuum extraction
TYPES
 removal of baby
1. Threatened o after discharged – ask
 s/s the woman to assess
o scant vaginal bleeding vaginal bleeding by
o slight cramping recording the number of
o cervix is closed pads she uses
 txt  6-8 pads/day –
o ask to come to the clinic normal
to have FHT to be
checked or UTZ to 3. Complete
evaluate the viability of  s/s
fetus o The entire products of
o HCG test = double conception are expelled
 spontaneously without o Prostaglandin
resistance suppository or
o D&C is done to be sure misoprostol (Cytotec) if
4. Incomplete pregnancy is over 14
 s/s weeks, to dilate the
o part of the fetus cervix
(usually the fetus) is o Oxytocin stimulation of
expelled but the administration of
membrane or placenta is mifepristone
retained in the uterus o DIC – disseminate
 txt intravascular coagulation
o D&C or suction  Increase
curettage to evacuate bleeding
the remainder of 6. Recurrent pregnancy/habitual
pregnancy  Always experiencing abortion
 Placenta and  s/s
membranes are o defective spermatozoa
still in the uterus or ova
– prevents uterus  abnormal fetal
to contract and development
cause profuse o deviation of the uterus
bleeding such as bicornuate
5. Missed/early pregnancy failure uterus
 s/s  divided into 2 at
o fetus die in the uterus the center
but is not expelled  shape like horn
o determine when the  prevents
fetus does not increase development of
in size baby
o no FHT o chorioamnionitis or
o fetus dies at 4-6 weeks uterine infection
before the onset of
miscarriage
o blood is dark and COMPLICATIONS
different odor
 Hemorrhage
 txt
 Infection
o UTZ
 Septic abortion
o D&E
o Self-abortion
 o Insert something to kill the
baby
 If left untreated = toxic shock
syndrome, septicemia, kidney
failure, death
NURSING MANAGEMENT
 Perform the appropriate
management and prevent
complications
 Monitor vital signs, bleeding and
pain
 Document IVF, lab test and
prepare for emergency surgical
intervention
 Prepare administration of RhoGAM
to Rh (-) mother
 Advise iron supplement
 Refraining from sexual intercourse
until next menses and advise use of
barrier contraception
A – age before viability
B – bleeding is scant, low abdominal
cramps, fever
O – observe for infection, hemorrhage
R – record v/s, bleeding, pain and IVF
T – toxic shock syndrome, septicemia,
kidney failure, death
I – inject RhoGAM, give iron
supplement
O – ovary fails to produce
progesterone
N – no sexual intercourse, notify HCP
HYPEREMESIS GRAVIDARUM
 Pernicious or persistent vomiting
 N/V that is prolonged, beyond 12
weeks
 Severe dehydration, weight loss
 Associated with helicobacter pylori
(causes peptic ulcer)
 Elevated hcg – first hormone
produced by placenta
 Could lead to fluid and electrolyte
imbalance and nutritional imbalance
o No food will be retained and
absorb in the body
 Assessment:
o Severe N/V
 Causes weakness and
confusion
o Elevated hct due to
dehydration
o Low Na, K, and chloride
o Hypokalemic
o Polyneuritis – numbness and
tingling sensation
o Weight loss – decrease
intake
o Urine test (+) for ketones
 Client is unable to
eat
 Body will be making
use of fat as a
source of energy
o Poor skin turgor and mucous
membrane
o If left untreated,
associated with intrauterine
restriction, preterm birth,
fetal death
  Malnourished and
small baby because
of growth and
development
restriction
 Therapeutic management:
o Hospitalization to receive
fluid replacement
 Lactated ringer
solution (3L) with
vitamin B – to
improve numbness
o Withheld oral food and
fluid
o Antiemetic –
metoclopramide or reglan
o Measure I and O and
amount of vomitus
o If no vomiting within 24 hrs
– may start small amount of
clear liquids
 Small frequent
feeding
o Dry crackers, dry toast or
cereal be added every 2
hours the soft diet
o If vomiting return – TPN is
used
 Risk of fluid and
electrolyte and
nutritional imbalance
 Nursing care management
o Ensure that the client has
no oral intake until vomiting
stops
o Administer IVF
o Record I and O
o Advise SFF once vomiting
has subsided
o Administer antiemetics as
prescribed
o Attends to client’s
emotional and psychological
needs
 E – exaggerated N/V beyond 1st
trimester
 M – metabolic alkalosis,
hypoproteinemia
o Vomiting hypoproteinemia
– use of protein
 E – electrolyte, fluid, vitamins and
minerals replacement and nutrition
 S – skin turgor and mucus
membrane assessment for
dehydration
 I – ingest bland solid foods
o Avoid foods that are spicy,
oily, and greasy
 S – strict hygiene and bedrest
o More on oral hygiene
o Bedrest as the client is
weak
GESTATIONAL TROPHOBLASTIC
DISEASE / HYDATIDIFORM MOLE
(H-MOLE) – molar pregnancy
 An abnormal proliferation and
degeneration of the trophoblastic
villi
 As the cells degenerate, they
become filled and appear as clear
fluid filled, grape-sized vesicles
 Trophoblast was formed from
placenta
 There was no placenta formed
during pregnancy
 Risk factors:
o Low protein intake
o Women older than 35 y/o
o Blood group A who marries
group O men
TYPES
1. Complete mole
 All trophoblastic villi swell and
become cystic
 If embryo form, it dies at 1-2
mm in size with no fetal blood
present in the villi
 Empty ovum – the sperm enters
empty egg and its chromosome
replicates
 Snowstorm – can be seen in
UTZ
2. Partial mole
 Some of the villi form normally
syncytiotrophoblastic (outer)
layer of villi is swollen and
misshapen
o Layer responsible in
producing maternal
hormones
 A macerated embryo of approx.
9 weeks gestation may be
present and fetal blood may be
present in the villi
 Has 69 chromosomes
 Rarely lead to choriocarcinoma
o But client is high risk to
have choriocarcinoma –
cancer that affects the
fetal membrane
ASSESSMENT
 Uterus tends to expand faster
than normally
 + urine test of HCG (1-2M)
o NV: 400,000 IU
o Could lead to enlargement
of uterus - unusual
 Marked N/V
 UTZ show dense growth (snowflake
pattern)
o It will confirm the presence
of mole
 (-) FHR – no baby inside the uterus
 Vaginal bleeding (approx. 16 weeks)
– dark brown
 Early s/s of preeclampsia
o Proteinuria, edema, HPN
before 20th week
MANAGEMENT
 Suction curettage
 Pelvic exam
 Chest xray
 Serum test for HCG
 o Every 2 weeks until normal 2nd TRIMESTER BLEEDING:
o Every month for 6 months INCOMPETENT CERVIX –
o Every 2 months for a total premature cervical dilatation
of 1 year
 Premature cervical dilatation
o There should be negative
 Inability of the cervix to support
HCG within a year
growing weight of pregnancy
o Positive HCG – client still
associate with repeated
has h-mole
spontaneous 2nd trimester abortion
o Clients are discouraged to
 Painless dilatation of the cervix in
be pregnant withing 1 year
the absence of uterine
due to hcg monitoring
contractions
 Use oral contraceptive (progestin)
o Dilates too early as early as
o Not COC
20 weeks or 5 months
o Should only contain
o Could lead to the delivery
progesterone due to risk of
of the viable fetus –
choriocarcinoma
weakened tissue of the
o Estrogen could facilitate
cervix
the regrowth of cancer
 Assessment:
cells
o Bloody show
 Methotrexate – drug of choice for
 Pink-stained vaginal
choriocarcinoma
bleeding
 Dactinomycin – added regimen if
 1st symptom
metastasis occur
o Increased pelvic
 H – HCG is elevated, uterus is large
pressure/low abdominal
for gestational age, persistent
pressure
bleeding, N/V
o Followed by rupture of
 M – mole is detected by UTZ and
membranes
removed by vacuum aspiration and
 BOW ruptures,
curettage
uterine contraction
 O – observe for s/s of shock,
is present affecting
prepare for BT and IV
cervical dilatations
 L – lower the risk by avoiding
o Uterine contractions begins
pregnancy for at least 1 year
and a short labor, the fetus
 E - educated on the need to
is born if present
monitor HCG for 1 year
o Occurs approx. week 20 of
pregnancy
o Progressive dilatation of
the cervix
 o Urinary frequency o Bedrest
 Affecting the o Coitus is temporarily
bladder during restricted – could lead to
dilatation or delivery infection
 Risk factors: o Tocolytic drug (ritodrine,
o Maternal age terbutaline)
o Congenital structural  Stop uterine
defects contraction
o Trauma to the cervix  I – inability of the cervix to
 Repeated abortion support the growing baby
 D&C  N – no douching
 Frequent insertion  C – cervical cerclage
of instrument  O – occur at week 20, blood show –
 Treatment: pink
o Cervical cerclage –  M – maternal age, congenital
performed between 14-16 structure defects, trauma of
weeks pregnancy because no cervix
thinning and shortening of  P – premature cervical dilation
cervix without uterine contraction
o Mc Donald – temporary  E – elevated pelvic pressure
(NSD)  T – Trendelenburg (modified)
 Sewing the cervix to  E – encourage bed rest
prevent the early  N – no coitus temporarily
delivery  T – tocolytic drug
 Removing the suture  only during 2nd pregnancy will be
at 38th weeks able to know if the client is
wherein the baby will experiencing incompetent cervix
be delivered
o Shirodkar – permanent (CS)
 Suture will not be
removed
 Removing after birth
 Nursing management:
o Modified Trendelenburg
position
 To decrease
pressure in the
pelvic area